Basic Information
| Provider Information | |||||||||
| NPI: | 1396251740 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MANDALAY OPTICAL LABS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 905 WESTMINSTER ST | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029034020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4013317850 | ||||||||
| FaxNumber: | 4013317850 | ||||||||
| Practice Location | |||||||||
| Address1: | 905 WESTMINSTER ST | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029034020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4013317850 | ||||||||
| FaxNumber: | 4013317850 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2017 | ||||||||
| LastUpdateDate: | 12/21/2017 | ||||||||
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| AuthorizedOfficialLastName: | COLONNA | ||||||||
| AuthorizedOfficialFirstName: | SCOTT | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4013317850 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | OD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | ODTA00491 | RI | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 1538169784 | 05 | RI | MEDICAID |